The Centers for Disease Control (CDC) maintains a webpage dedicated to providing updated recommendations to airlines on high-interest infectious diseases. The current website offers guidance to airlines on the measles, flu, cholera, and Middle-East respiratory syndrome (MERS). On August 11 2014, they added airline guidance for Ebola. Ultimately, the CDC’s recommendations emphasize the fact that Ebola IS NOT spread by airborne or respiratory droplets and therefore risk of rapid global spread remains low, unlike many of the other diseases stated above. But before going into the specific CDC guidance to airlines, it is important to understand and review the basic facts surrounding this serious and terrible disease.
EBOLA HEMORRHAGIC FEVER
The 2014 outbreak of Ebola, which started in March of this year, at the time of this writing has affected 4 West African Countries – Guinea, Sierra Leone, Liberia, and Nigeria. As of 19 Aug 2014, the World Health Organization (WHO) has reported 2240 suspected and confirmed cases of Ebola, including 1383 laboratory-confirmed cases, and 1229 deaths (54.9% mortality). This is not the first outbreak of Ebola. The virus was first identified in 1976 in the Republic of Congo, gaining its name from the nearby Ebola River. The last outbreak was in 2012 when Uganda and the Republic of Congo experienced a smaller scale epidemic, which lasted from July to December of that year. Other outbreaks have occurred in Gabon, Sudan and the Ivory Coast and can be seen in detail by clicking the above photo. The disease currently stirring so much attention is called Ebola Hemorrhagic Fever and is caused by an RNA virus in the filovirus family. There are 5 separate Ebola virus species. Ebola is considered a viral hemorrhagic fever, though it is much more fatal than many other hemorrhagic fevers such as Dengue or Yellow Fever. The pathogenesis is complex, but basically the viruses causing these diseases provoke small blood clots throughout the body, disrupt the clotting cascade and generally attack the lining of blood vessels and/or platelets. Many of the initial symptoms of Ebola are vague and non-specific making early diagnosis difficult:
- Fever (greater than 38.6°C or 101.5°F)
- Severe headache
- Muscle pain
- Weakness
- Diarrhea
- Vomiting
- Abdominal (stomach) pain
- Lack of appetite
The incubation period for the virus is 2 to 21 days after exposure, but 8-10 days seems to be the most common incubation period prior to symptom onset. At this point, the true reservoir for the virus is unknown, but many have speculated that bats are the likely culprit. The virus has also been identified in non-human primates and pigs. Once humans are infected (after likely ingesting infected animal tissue), the virus can spread from person to person by direct contact of contaminated fluids. The Ebola virus’ ability to spread is limited:
- Sick person’s blood or body fluids (urine, saliva, feces, vomit, and semen)
- Contaminated objects (such as needles) with infected body fluids
- Infected animal tissue
Because of the need for direct contact for transmission, the groups of people at biggest risk for contracting the disease are family members and healthcare workers in close proximity to infected patients and their bodily fluids. The fact that the disease does not spread by respiratory droplets has led many public health policy makers to rank the risk of a global outbreak of ebola as quite low. Given the vague, non-specific symptoms of Ebola; diagnoses are often delayed. The diagnosis is confirmed via lab assessment of a blood sample, by doing either viral cultures and reverse transcriptase polymerase chain reaction (PCR) to identify the virus, or enzyme-linked immunosorbent assay (ELISA) to identify antibodies. There is currently no proven antiviral treatment or vaccination for Ebola Hemorrhagic Disease. The mainstay of current treatment is supportive therapy in the form of fluids, oxygen, and life support as required. Several vaccinations are currently in the test phase, but none have yet proven safety and efficacy. ZMapp, being developed by Mapp Biopharmaceutical Inc., is an experimental treatment for Ebola. It has not yet been tested in humans. According to the manufacturer, ZMapp is “composed of three “humanized” monoclonal antibodies manufactured in plants ” that bind to the protein of the Ebola virus. In an incredibly rare event, the FDA has permitted this experimental drug to be used to treat Ebola in a few cases. The two American missionary healthcare workers recently infected with Ebola were provided this new experimental drug. According to the CDC: “This experimental treatment was arranged privately by Samaritan’s Purse, the private humanitarian organization, which employed one of the Americans who contracted the virus in Liberia. Samaritan’s Purse contacted the Centers for Disease Control and Prevention (CDC), who referred them to the National Institutes of Health (NIH). NIH was able to provide the organization with the appropriate contacts at the private company developing this treatment. The NIH was not involved with procuring, transporting, approving, or administering the experimental treatments.“ The two Americans who received the experimental drug seem to be improving, but a Spanish priest also provided the drug for its third use did not recover and subsequently died of the disease.
As a consequence of the significant mortality and nature of the disease, public hysteria continues to rise. Mass quarantines are being implemented as public health and government agencies scramble to develop plans and guidance to prevent spread and respond to the disease in the event that it does extend outside West Africa. Quarantine zones have been established in high transmission areas including the severely affected cities in Guinea, Liberia; and Sierra Leone. Liberian soldiers along the border with Sierra Leone have been ordered to shoot anyone attempting to cross the border at night. And countries with Ebola cases have been requested to conduct an exit screening of all persons at entry/exit points of the country. Obviously, the existence of international air travel adds a new variable in rapid disease spread that did not exist 100 years ago.
CDC RECOMMENDATIONS FOR AIRLINES
Released on 11 Aug 2014, the CDC report provides guidance to Airlines in respect to the Ebola Outbreak. Here are some highlights:
- Any person exposed to Ebola should not be permitted aboard commercial airliners until 21 days of observation and medical clearance by their physician.
- Any airplane traveling to a country affected by Ebola (currently Sierra Leone, Liberia, Guinea, and now Nigeria) should have a universal precautions kit on board.
- In addition to standard in-flight medical services, the CDC should be contacted for guidance if suspicion for an Ebola-infected passenger for any flights into the United States.
- Treat any bodily fluids as if contaminated. Personnel tasked to clean bodily fluids from within airlines need to wear impermeable plastic gloves and use an EPA approved cleaner. Other specific guidance is provided.
- Since Ebola virus is spread through direct contact of bodily fluids, cargo does not bear any risk unless soiled with blood or other infected bodily fluids.
CDC RECOMMENDATION FOR HEALTHCARE WORKERS
The CDC also has a page of resources specifically drafted for healthcare workers. For those interested, click the link above.
THE WHO’S APPROACH & RESPONSE TO THE EBOLA OUTBREAK
REFERENCES
1. CDC Ebola Hemorrhagic Fever. Accessed 19 Aug 2014. 2. WHO Ebola Fact Sheet. Accessed 19 Aug 2014. 3. Paessler S, Walker DH. Pathogenesis of the viral hemorrhagic fevers. Annu Rev Pathol. 2013 Jan 24;8:411-40. Epub 2012 Nov 1.
World Health Organization (WHO), 27 Aug 2014: More than 240 health care workers (HCWs) (including 120 deaths) have contracted EVD due to the magnitude and duration of the unprecedented outbreak, with resultant stress on the quality of the health care response. Health care facilities have closed due to shortages of HCWs, many of whom are refusing to work. Other health care needs are not being met.
Travelers to and residents of affected areas with unrelated medical problems are not being accepted by hospitals in Europe or other countries to which they would be evacuated otherwise. Air ambulance flights originating in affected areas are being refused landing permits for either refueling or hospital transfers in any other country no matter the patient problem.
Shoreland TRAVAX, 1 Sep 2014: The health care system in most areas of Guinea, Liberia, and Sierra Leone has collapsed, and most hospitals are closed. Travelers should not have an expectation of in-patient care being available for any type of unrelated medical conditions. Travelers are subject to local controls and regulations regarding quarantine and isolation and cannot expect intervention by consular authorities from their home country. According to International SOS and other commercial evacuation carriers, international air evacuation should not be considered as feasible for patients with active clinical symptoms of Ebola virus disease (EVD).
Due to increasingly limited commercial flight options and absence of seat availability, persons without access to chartered flights organized by international organizations are unlikely to be able to depart affected countries at the present time. At this time, only Royal Air Maroc and Brussels airlines are offering scheduled flights to Liberia, Guinea, or Sierra Leone with a limited schedule totaling no more than 15 flights per week to the region.
Shoreland TRAVAX, 5 Sep 2014: In animal trials, all 18 monkeys given ZMapp, a recombinant antibody cocktail, were protected from a lethal challenge with Zaire Ebola virus which may differ from the currently circulating strains which show a rapid pattern of mutation
A WHO expert panel concluded that convalescent blood and serum therapies are a priority and that a few novel therapeutic drugs have shown promise in animals, but no efficacy data in humans are available. Safety studies on 2 vaccine candidates in the absence of any efficacy data would allow an experimental vaccine to be available in November 2014 for priority use in health care workers
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Shoreland TRAVAX, 8 Sep 2014: Cote d’Ivoire and Senegal will open humanitarian corridors, while still maintaining closed borders, to allow relief organizations access to EVD-affected countries.
According to press sources, the government of Sierra Leone will commence a nationwide shutdown to search for EVD cases, from September 19 to 21, 2014. Residents will be confined to their homes and pedestrians and vehicles will be barred from the country’s streets, except on official business.
The U.S. military will set up a 25-bed field hospital in Liberia, which will then be completely staffed by the Liberian government. The U.S. president has raised the possibility of U.S. military protection for health care workers.
Shoreland TRAVAX, 12 Sep 2014: The Ebola virus disease (EVD) outbreak continues to accelerate with no indication of any down-turn in the epidemic in Guinea, Liberia, or Sierra Leone. A sharp increase in new cases in Monrovia, Liberia, has resulted in almost double the number of newly reported cases in Liberia over the previous week.
Foreigners in Sierra Leone should prepare for the government’s Ebola public awareness campaign (September 19-21, 2014) during which there will be no access to local businesses and services, government services, and their own consular services.
According to WHO, the 2 previously reported suspected cases of EVD in Senegal have tested negative but will continue to be monitored. To date, only 1 confirmed case of EVD (imported) has been reported in Senegal.
World Health Organization (WHO), 18 Sep 2014: 348 cases of Ebola virus disease (EVD) and 186 deaths have been reported among health care workers (HCWs) from Guinea, Liberia, Nigeria, and Sierra Leone as of September 22, 2014. EVD among HCWs continues to rapidly increase, with the largest burden of cases occurring in Liberia (174 cases and 85 deaths) and Sierra Leone (96 cases and 61 deaths).
Shoreland TRAVAX, 18 Sep 2014: Airborne transmission between humans has not been shown to occur during this or earlier outbreaks. The possibility of aerosol formation from heavily virus-laden body fluids contaminating the environment has been raised by some investigators. At present, CDC, WHO, and MSF guidelines recommend droplet and contact precautions only for routine in-patient care of EVD patients both in affected areas as well as for those evacuated to resource-rich environments. Airborne precautions, which include the use of N95/FFP2 filtering facepiece respirators or higher (e.g., powered air purifying respiratory [PAPR] suits), are only recommended by CDC and WHO for aerosol inducing procedures. In practice, to date, in robust resource-rich settings clinicians and clinical units accepting patients have all used a negative pressure environment, airborne precautions, and PAPR or near PAPR-like devices for all direct patient care activities.
Shoreland TRAVAX, 23 Sep 2014: Based on analysis of case data and prediction modeling, both WHO and CDC estimate that under current conditions and with the current level of interventions, Ebola virus disease (EVD) cases will continue to double approximately every 20 days. Estimates of actual numbers of cases in the future are difficult to make as the true number of current cases is not known with any certainty.
According to Swiss authorities, a suspected case of EVD with a high-risk exposure is currently hospitalized in Lausanne. A Guinean man with a history of a family member who had died of EVD departed Guinea on September 15, 2014, and was immediately hospitalized in Switzerland on September 17 while asymptomatic. The man became febrile on September 23; EVD test results are pending.
The Center for Disease Control (CDC) released a report in late September 2014 describing a possible ‘worst-case scenario’ to the 2014 Ebola Outbreak affecting West Africa. Although the media has published a variety of provocative magazine covers and headlines in response to this report, it is critical to understand the CDC’s report is written with the assumption that the current and past response by global public health organizations DO NOT change. This is a call for change in funding and seriousness of this outbreak.
The CDC reports that “without additional interventions or changes in community behavior, CDC estimates that by January 20, 2015, there will be a total of approximately 550,000 Ebola cases in Liberia and Sierra Leone or 1.4 million if corrections for underreporting are made.” Yes, 1.4 million cases! This is clearly a gloomy prediction, but there is no talk that ‘Ebola is Coming’ as some highly popular and well-respected magazine have implied or directly stated in an effort to sell magazines.
The Key Messages provided by the CDC are:
•If conditions remain unchanged, the situation will rapidly become much worse.
•We know how to control and eventually stop the epidemic. Halting the epidemic requires placing up to 70% of patients into either an Ebola Treatment Unit or in a community setting in which the risk of disease transmission is reduced and safe burials are provided.
•The cost of delay will be devastating. The number of cases is doubling about every 20 days. Every month of delay in reaching the 70% target will increase the number of patients, which means more cases and more deaths and the need for even more beds and other resources.
30 September 2014: CDC confirms first case of Ebola diagnosed outside of Africa- in Dallas, TX.
According to the Center for Disease Control (CDC) , “one imported laboratory-confirmed case of Ebola virus disease (EVD) has been reported in Dallas, Texas State, on September 30, 2014. This is the first ever Ebola Zaire infection diagnosed outside of Africa. The African traveler was asymptomatic on commercial flights from Liberia to the U.S. on September 19 and 20, became symptomatic with fever and vomiting on September 24, sought hospital care but was released on September 26, and was subsequently admitted to the Texas Health Presbyterian Hospital Dallas on September 28. He is known to have stayed with family in the Dallas area, and initial indications are of limited community contact, although the epidemiological investigation has just been initiated. EVD is not contagious during the asymptomatic phase. All contacts of this traveler while he was symptomatic will be contacted by the Texas Department of Health with support from the CDC and followed daily for 21 days. EVD should be considered in any person presenting with abrupt onset of fever or extreme malaise within 2-21 days of contact with this traveler. The risk of community-based or sustained transmission is very low.”
30 September 2014: CDC confirms first case of Ebola diagnosed outside of Africa- in Dallas, TX.
According to Center for Disease Control (CDC), “one imported laboratory-confirmed case of Ebola virus disease (EVD) has been reported in Dallas, Texas State, on September 30, 2014. This is the first ever Ebola Zaire infection diagnosed outside of Africa. The African traveler was asymptomatic on commercial flights from Liberia to the U.S. on September 19 and 20, became symptomatic with fever and vomiting on September 24, sought hospital care but was released on September 26, and was subsequently admitted to the Texas Health Presbyterian Hospital Dallas on September 28. He is known to have stayed with family in the Dallas area, and initial indications are of limited community contact, although the epidemiological investigation has just been initiated. EVD is not contagious during the asymptomatic phase. All contacts of this traveler while he was symptomatic will be contacted by the Texas Department of Health with support from the CDC and followed daily for 21 days. EVD should be considered in any person presenting with abrupt onset of fever or extreme malaise within 2-21 days of contact with this traveler. The risk of community-based or sustained transmission is very low.”
WHO recommends pursuit of 2 vaccines for Ebola:
WHO recommends that 2 candidate vaccines, cAd3-ZEBOV (GSK) and rVSV-ZEBOV (Newlink Genetics), for which clinical-grade material is already available, be pursued. A multi-center Phase 1 safety/immunogenicity trial of cAd3-ZEBOV is currently underway, and an rVSV-ZEBOV trial is imminent. Both pharmaceutical companies are working to increase their manufacturing capacities.
Updates & Background on Liberian man diagnosed with Ebola in Dallas, TX:
According to press sources, the recently reported imported case in Dallas, Texas, U.S. is a Liberian national who traveled aboard Brussels Airlines from Monrovia, Liberia via Brussels, Belgium to visit family in the Dallas area. Preliminary reports indicate that once symptomatic 4 days after arrival, he came into contact with at least 12 to 18 people (including 5 school-aged children), none of whom are ill at present; all are to be closely monitored with twice-daily temperature checks. Apparently the patient was seen in a Texas ER and released due to a breakdown in communication only a few days prior to returning and having the disease confirmed by the laboratory. USA Today is also currently reporting that a close contact of this patient is now a “possible second Ebola case” and some news sources state that over 100 contacts are being monitored.
Shoreland TRAVAX, October 8, 2014: TheTexas Department of State Health Services reported that the imported case of EVD in Dallas died. The Liberian national, who traveled from the EVD-affected country, was initially reported to have come into contact with more than 40 people, but the number ultimately increased to 100 contacts.
Brincidofovir (Chimerix Inc.), an experimental oral nucleotide analog, has been approved by the FDA for use in treating EVD patients through an Emergency Investigational New Drug (EIND) application. In vitro data suggest brincidofovir activity against Ebola virus.
European Centre for Disease Prevention and Control (ECDC) has recommended that returnees from EVD-affected countries be deferred from donating blood or tissue for 2 months after return.
The global total is now 8,399 cases (including 4,033 deaths) since January 2014. Health care worker (HCW) exposures continue to be a troubling aspect of this outbreak, with 416 cases (including 233 deaths) reported in HCWs
Shoreland TRAVAX, 12 Oct 2014: According to the CDC, a health care worker (HCW) in Dallas, Texas, who provided care to the Ebola virus disease (EVD) index case in that city has tested positive for EVD. This is the second EVD case diagnosed in the U.S. and the first case acquired within the country. Nina Pham self-identified herself and reports to have self-monitored twice daily and was isolated within 90 minutes after fever was noted. The single close contact of this HCW during the time she was symptomatic has been placed into isolation. Pham stated that existing CDC protocols for general U.S. health care facilities by using mask, gown, gloves, and face shield were followed without known incident. CDC has stated that an inadvertent breach in protocol must have occurred.
CDC Director Tom Frieden stated that the care of EVD in general hospitals is difficult to do safely as it requires meticulous and scrupulous attention to infection control, and even a single inadvertent slip can result in contamination. Specialized containment units in Atlanta, Georgia; Washington, D.C.; and Omaha, Nebraska have been using more stringent barrier procedures and have trained extensively on the PPE doffing procedures thought most likely to result in self-contamination of HCWs caring for EVD patients.
Shoreland TRAVAX, 12 Oct 2014: According to the CDC, a health care worker (HCW) in Dallas, Texas, who provided care to the Ebola virus disease (EVD) index case in that city has tested positive for EVD. This is the second EVD case diagnosed in the U.S. and the first case acquired within the country. Nina Pham self-identified herself and reports to have self-monitored twice daily and was isolated within 90 minutes after fever was noted. The single close contact of this HCW during the time she was symptomatic has been placed into isolation. Pham stated that existing CDC protocols for general U.S. health care facilities by using mask, gown, gloves, and face shield were followed without known incident. CDC has stated that an inadvertent breach in protocol must have occurred.
CDC Director Tom Frieden stated that the care of EVD in general hospitals is difficult to do safely as it requires meticulous and scrupulous attention to infection control, and even a single inadvertent slip can result in contamination. Specialized containment units in Atlanta, Georgia; Washington, D.C.; and Omaha, Nebraska have been using more stringent barrier procedures and have trained extensively on the PPE doffing procedures thought most likely to result in self-contamination of HCWs caring for EVD patients.
Shoreland TRAVAX, 12 Oct 2014: According to the CDC, a health care worker (HCW) in Dallas, Texas, who provided care to the Ebola virus disease (EVD) index case in that city has tested positive for EVD. This is the second EVD case diagnosed in the U.S. and the first case acquired within the country. Nina Pham self-identified herself and reports to have self-monitored twice daily and was isolated within 90 minutes after fever was noted. The single close contact of this HCW during the time she was symptomatic has been placed into isolation. Pham stated that existing CDC protocols for general U.S. health care facilities by using mask, gown, gloves, and face shield were followed without known incident. CDC has stated that an inadvertent breach in protocol must have occurred.
CDC Director Tom Frieden stated that the care of EVD in general hospitals is difficult to do safely as it requires meticulous and scrupulous attention to infection control, and even a single inadvertent slip can result in contamination. Specialized containment units in Atlanta, Georgia; Washington, D.C.; and Omaha, Nebraska have been using more stringent barrier procedures and have trained extensively on the PPE doffing procedures thought most likely to result in self-contamination of HCWs caring for EVD patients.